Your Free Guide to Medicare

Your Free Guide to Medicare

What is Medicare?

Medicare is a federal program that provides health insurance to seniors and disabled individuals in the United States. Treatment is covered through a combination of individual fees and trust funds built up through employee taxes. It is managed by the Centers for Medicare & Medicaid Services (CMS), a federal department. 

Medicare is available for:

• Individuals 65 years of age and older
• Individuals with end-stage renal disease (ESRD)
• Some younger individuals with disabilities

The coverage you receive through Medicare depends on what Medicare programs you are enrolled in. Review the section “Programs In Medicare” to learn more about your coverage options.

To learn about how to qualify for Medicare based on disability, see the section “Defining Disability.” 

Medicare vs. Medicaid

While Medicare generally provides health insurance for seniors, Medicaid is designed to provide coverage for low income individuals and families including children, adults, and pregnant women. 

Medicaid eligibility can extend to disabled individuals and seniors who also receive Medicare. Individuals who are eligible for both Medicare and Medicaid are referred to as “dual-eligible.” 

Although Medicare and Medicaid are both operated by the Centers for Medicare & Medicaid Services (CMS), they are separate programs. Medicaid is jointly funded by the federal and state governments. As a result, eligibility requirements, coverage and costs vary from state to state. 

While Medicare enrollment is generally limited to particular times of the year or after certain life events, applications for Medicaid are open throughout the year. 

For more information on Medicare enrollment and when to enroll, refer to the section “How to Apply for Medicare” of this guide.

Medicare Contact Information

General Medicare Contact Information

Centers for Medicare & Medicaid Services Regional Office Contact Information

Note: The District of Columbia, Maryland and West Virginia do not have regional CMS offices. Instead, residents from these areas may contact the general Medicare phone line above. 

State/Territory	Regional Office	Phone Number
Alabama	Atlanta Regional Office	(404) 562-1738
Alaska	Seattle Regional Office	(206) 615-2308
American Samoa	San Francisco Regional Office	(415) 744-3502
Arizona	San Francisco Regional Office	(415) 744-3502
Arkansas	Dallas Regional Office	(214) 767-6423
California	San Francisco Regional Office	(415) 744-3502
Colorado	Denver Regional Office	(303) 844-1568
Connecticut	Boston Regional Office	(617) 565-1185
Delaware	Philadelphia Regional Office	(215) 861-4140
District of Columbia	N/A	N/A
Florida	Atlanta Regional Office	(404) 562-1738
Georgia	Atlanta Regional Office	(404) 562-1738
Guam	San Francisco Regional Office	(415) 744-3502
Hawaii	San Francisco Regional Office	(415) 744-3502
Idaho	Seattle Regional Office	(206) 615-2308
Illinois	Chicago Regional Office	(312) 886-5344
Indiana	Chicago Regional Office	(312) 886-5344
Iowa	Kansas City Regional Office	(816) 426-5233
Kansas	Kansas City Regional Office	(816) 426-5233
Kentucky	Atlanta Regional Office	(404) 562-1738
Louisiana	Dallas Regional Office	(214) 767-6423
Maine	Boston Regional Office	(617) 565-1185
Maryland	N/A	N/A
Massachusetts	Boston Regional Office	(617) 565-1185
Michigan	Chicago Regional Office	(312) 886-5344
Minnesota	Chicago Regional Office	(312) 886-5344
Mississippi	Atlanta Regional Office	(404) 562-1738
Missouri	Kansas City Regional Office	(816) 426-5233
Montana	Denver Regional Office	(303) 844-7118
Nebraska	Kansas City Regional Office	(816) 426-5233
Nevada	San Francisco Regional Office	(415) 744-3502
New Hampshire	Boston Regional Office	(617) 565-1185
New Jersey	New York Regional Office	Toll-Free: (877) 449-5661 Local: (212) 616-2229
New Mexico	Dallas Regional Office	(214) 767-6423
New York	New York Regional Office	Toll-Free: (877) 449-5661 Local: (212) 616-2229
North Carolina	Atlanta Regional Office	(404) 562-1738
North Dakota	Denver Regional Office	(303) 844-7118
Northern Mariana Islands	San Francisco Regional Office	(415) 744-3502
Ohio	Chicago Regional Office	(312) 886-5344
Oklahoma	Dallas Regional Office	(214) 767-6423
Oregon	Seattle Regional Office	(206) 615-2308
Pennsylvania	Philadelphia Regional Office	(215) 861-4140
Puerto Rico	New York Regional Office	Toll Free: (877) 449-5661 Local: (212) 616-2229
Rhode Island	Boston Regional Office	(617) 565-1185
South Carolina	Atlanta Regional Office	(404) 562-1738
South Dakota	Denver Regional Office	(303) 844-7118
Tennessee	Atlanta Regional Office	(404) 562-1738
Texas	Dallas Regional Office	(214) 767-6423
U.S. Virgin Islands	New York Regional Office	Toll Free: (877) 449-5661 Local: (212) 616-2229
Utah	Denver Regional Office	(303) 844-7118
Vermont	Boston Regional Office	(617) 565-1185
Virginia	Philadelphia Regional Office	(215) 861-4140
Washington	Seattle Regional Office	(206) 615-2308
West Virginia	N/A	N/A
Wisconsin	Chicago Regional Office	(312) 886-5344
Wyoming	Denver Regional Office	(303) 844-7118

Additional Contact Resources

You can find more contact information and resources by organization, state and/or by topic of interest at https://www.cms.gov/Center/Freedom-of-Information-Act/regional-contacts.htm.

Programs in Medicare

Medicare is divided into several different components, each of which has a different function. This section will provide information on the different programs, namely: 

• Medicare Part A, hospital coverage
• Medicare Part B, medical coverage
• Medicare Part C, Medicare Advantage plans (including Special Needs Plans)
• Medicare Part D, prescription drug coverage
• Medigap Policies, plans that cover services not fully covered by Medicare
• Program of All-Inclusive Care for the Elderly (PACE)

Medicare Part A

Medicare Part A provides hospital-related coverage. All individuals who receive Medicare have Part A coverage. This encompasses:

• Long-term hospital care
• Inpatient hospital care
  • Semi-private rooms
  • Meals
  • General nursing
  • Medication
  • Other hospital services and supplies
• Inpatient mental health care
  • General hospital admissions
  • Psychiatric facility admissions
• Skilled nursing facility care
  • Semi-private room
  • Meals
  • Skilled nursing care
  • Physical therapy
  • Occupational therapy
  • Speech-language pathology services
  • Medical social services
  • Medication
  • Medical supplies and equipment
  • Ambulance transportation
  • Dietary counseling
  • Swing bed services
• Nursing home care
• Hospice care
• Home health care
• Part-time or “intermittent” skilled nursing care
  • Physical therapy
  • Occupational therapy
  • Speech-language pathology services
  • Medical social services
  • Part-time or intermittent home health aide services (personal hands-on care)
  • Injectable osteoporosis drugs for women

Who can get Medicare Part A?

Part A is typically available to the following individuals: 

• Adults age 65 and older
• Disabled individuals
• Individuals with End-Stage Renal Disease

How to Qualify for Medicare Based on Disability

Disabled individuals may be able to receive Medicare coverage even if they are younger than 65 years of age. To qualify, they must have received (or be entitled to receive) 24 months of disability benefits through Social Security or the Railroad Retirement Board (RRB). 

Enrollment into Medicare based on disability is automatic. Individuals should receive Medicare cards in the mail three months before their 25th month of receiving Social Security or Railroad Retirement Board disability benefits. These benefits are different from retirement benefits, which qualify beneficiaries for other Medicare perks. Learn about the benefits available from Social Security and the Railroad Retirement Board below.

What are Social Security Benefits?

The Social Security Administration (SSA) is an agency of the federal government that administers Social Security, a public insurance program that provides the following types of insurance benefits, each of which affects an individual’s qualifications for Medicare:

• Retirement benefits
• Disability benefits

Individuals can usually qualify for Social Security retirement benefits when they have worked and paid Social Security taxes for a period of 40 work credits, equivalent to roughly 10 years of employment.

Those who receive retirement benefits from the SSA generally qualify for premium-free Medicare Part A. Find more information about this in the “Medicare Part A Premiums” section of this guide. 

Individuals can qualify for Social Security disability benefits when they cannot work and meet the SSA’s definition of blind or disabled. Learn more about the definition of disability in the “Defining Disability” section of this guide.

What are Railroad Retirement Board Benefits?

The Railroad Retirement Board (RRB) is an agency of the federal government that administers the following types of insurance benefits to individuals who worked in the railroad industry, each of which affects an individual’s qualifications for Medicare:

• Retirement benefits
• Disability benefits

Individuals can qualify for RRB retirement benefits when they have accrued enough work hours in a railroad occupation. Those who receive retirement benefits from the RRB qualify for premium-free Medicare Part A. Find more information about this in the “Medicare Part A Premiums” section of this guide. 

Individuals can qualify for RRB disability benefits when they cannot work and meet the RRB’s definition of disabled. Learn more about the definition of disability in the “Defining Disability” section of this guide.

Defining Disability 

The Social Security Administration (SSA) and the Railroad Retirement Board (RRB) determine whether an individual’s condition meets the definition of “disabled.” 

The SSA determines you that you may qualify for benefits based on disability when all of the below are true:

• You cannot do the same work that you did before your disability.
  • The disability must directly affect work-related abilities, such as walking, lifting, remembering or sitting.
• You cannot adjust to other work because of your medical condition(s)/disability.
• Your disability has lasted or is expected to last for a period of at least one year or to result in death.

The RRB determines that you may qualify for benefits based on disability when you have a condition that leads to a permanent disability which prevents you from working. It considers you unable to work if you are unable to perform any of the following functions:

• Walking, standing, sitting, lifting, pulling, pushing, reaching, carrying or handling
• Seeing, hearing or speaking
• Understanding and remembering simple instructions
• Using judgment
• Responding appropriately to supervision, colleagues and common work situations
• Dealing with changes in the work setting

Individuals may need to meet other requirements to receive disability benefits from the SSA or RRB. 

For more information about Social Security benefits, visit the SSA website here: https://www.ssa.gov/disability/. 

For more information about Railroad Retirement benefits, visit the RRB website here: https://rrb.gov/RB-17b/PartII/EligibilityRequirementsforaDisabilityAnnuity. 

Medicare Part A Premiums

Most Medicare recipients qualify for premium-free Part A coverage.  A premium is a payment made by an insured individual in exchange for having coverage. With premium-free Medicare Part A coverage, enrollees are exempt from making these payments.

Who gets premium-free Medicare Part A coverage?

Premium-free Medicare Part A coverage is generally available to enrollees age 65 or older who:

• Already receive retirement benefits from Social Security or the Railroad Retirement Board; or
• Are eligible to receive retirement benefits from Social Security or the Railroad Retirement Board, but have not yet applied; or
• Had (or have a spouse who had) Medicare-covered government employment and paid Medicare taxes for at least 40 work quarters; or
• Are currently married with a spouse who is eligible for premium-free benefits; or
• Are currently divorced but were married for at least 10 years and the ex-spouse is eligible for premium-free benefits; or
• Are currently widowed but were married for at least nine months before the spouse died and the spouse was eligible for premium-free benefits.

Enrollees younger than 65 years of age can also qualify for premium-free Medicare Part A coverage if:

• They have received Social Security or Railroad Retirement Board disability benefits for 24 months.
• They have End-Stage Renal Disease (ESRD).

Who needs to pay Medicare Part A premiums?

Individuals who have paid Medicare taxes for fewer than 40 work quarters (10 years of work) are typically required to pay premiums for Medicare Part A coverage.

Those who do not qualify for premium-free Part A will be charged the following premiums in 2024:

• Enrollees with less than 30 quarters of work credits: $505 monthly
• Enrollees with 30-39 quarters of work credits: $278 monthly

Other Medicare Part A Expenses

In addition to premiums, Medicare Part A recipients will be required to pay the following fees for services:

Inpatient and Long-Term Hospital Care Service

Enrollees who are admitted into a hospital are receiving inpatient care. Long-term hospital care is a type of inpatient stay that averages 25 days or longer. Medicare Part A coverage has certain fees for inpatient services based on the length of stay during a given benefit period, which begins the first day the patient is admitted to the hospital and ends after they are discharged and have not been readmitted into a hospital for 60 consecutive days. There are no Medicare limits on benefit periods. This means that if a patient re-enters a hospital after their benefit period has ended, a new period begins. 

Medicare Part A covers up to 90 days of inpatient and long-term hospital care during each benefit period. Enrollees who stay longer than 90 days are given 60 additional days of coverage, which are known as lifetime reserve days. While benefit periods reset after each 60-day period without a hospital admission, lifetime reserve days do not. Enrollees are only provided a total of 60 lifetime reserve days. Once they use all 60 days, they cannot receive more.

Enrollees will be charged the following fees for inpatient and long-term hospital care service in 2024:

• $1,632 deductible per benefit period
  • A deductible is the amount of money an enrollee pays out-of-pocket for covered services before Medicare begins to pay.
• Days 1-60 of hospital admission: $0 coinsurance per day
• Days 61-90 of hospital admission: $408 coinsurance per day
  • Coinsurance refers to the enrollee’s shared expense of a covered service. It is an agreed-upon amount of money an enrollee pays out-of-pocket; the remaining cost is paid by Medicare.
• Days 91 and beyond of hospital admission: $816 coinsurance per lifetime reserve day 
• Days after lifetime limit: Responsible for full cost of care
• Enrollees also pay 20 percent of all Medicare-allowed costs for mental health services received from doctors while they are admitted in a mental health care facility.

Inpatient Mental Health Care Service

Medicare recipients are covered for inpatient mental health care services provided at general hospitals and psychiatric facilities. These services are intended to treat mental health conditions such as depression and anxiety. Medicare covers the cost of:

• Room and board
• Meals
• Nursing care
• Lab tests
• Medications
• Therapy and treatment for the patient’s condition

Medicare will not pay for the following in an inpatient mental health admission:

• Private duty nursing
• Television or phone in the patient’s room
• Personal items (i.e. toothpaste, socks, razors)
• A private room (unless a doctor states it is medically necessary)

There is no limit to inpatient mental health care services provided at general hospitals. However, there is a lifetime limit of 190 days of inpatient care at psychiatric facilities. In both settings, patients can have multiple benefit periods. 

Enrollees are charged for inpatient mental health care based on their length of stay during any given benefit period:

• $1,600 deductible per benefit period
• Days 1-60 of hospital admission: $0 coinsurance per day
• Days 61-90 of hospital admission: $400 coinsurance per day
• Days 91 and beyond of hospital admission: $800 coinsurance per lifetime reserve day 
• Days after lifetime limit: Responsible for full cost of care
• 20 percent of Medicare-allowed cost for mental health services received from doctors while they are inpatients
• Enrollees also pay 20 percent of all Medicare-allowed costs for mental health services received from doctors while they are admitted in a mental health care facility

Skilled Nursing Facility Service

Skilled nursing care is any health care treatment or service that can only be provided by a registered nurse or doctor. Enrollees receive this type of care at skilled nursing facilities (SNF) certified by Medicare. Medicare only covers SNF services if all of the following criteria are met:

• The enrollee has a qualifying hospital stay
  • Before entering a SNF, the enrollee must be admitted to a general hospital for a period of at least three days. 
  • If the enrollee leaves the SNF and re-enters within 30 days, he or she does not need another three days of inpatient care.
• The enrollee enters the SNF within 30 days of the qualifying hospital stay
• The enrollee has days left in his or her benefit period
• A doctor determines skilled nursing care is necessary for the treatment of a medical condition that:
  • Was treated during the qualifying hospital stay, even if it was not the reason for admission; or
  • Started while the enrollee was receiving care in a SNF for a hospital-related medical condition

Enrollees will be charged the following fees for SNF care:

• Days 1-20: $0
• Days 21-100: $200 coinsurance per day
• Days 101 and beyond: Responsible for full cost of care

Hospice Care

Medicare Part A enrollees pay nothing for hospice care, otherwise known as end-of-life care for terminal illnesses. However, they may need to pay a $5 copay per medication prescribed to them during this time. A co-pay (or copayment) is a fixed cost that the enrollee pays out of pocket for services, office visits or medications.

Enrollees may need to pay a portion of the cost for respite care, which is when the patient’s caregiver needs rest. If the patient is admitted into an inpatient facility while the caregiver rests, he or she may be responsible for up to 5 percent of the Medicare-allowed amount (the total amount a doctor or provider accepts for services). 

Medicare does not cover the cost of room and board. Hospice patients who receive care in their homes or in facilities in which they live (such as nursing facilities) are responsible for paying their own costs for food, shelter and utilities. However, if a hospice coordinator determines that an enrollee needs short-term care in a hospice facility, Medicare will cover the cost of the stay. 

Home Health Care

Medicare Part A enrollees pay nothing for home health care services, which refers to any services or treatments provided in the enrollee’s home by skilled health care professionals. However, those who require durable medical equipment (DME) may need to pay 20 percent of the Medicare-approved cost. DME is any equipment ordered by a doctor for use in the home, such as a cane, walker, wheelchair or hospital bed. Learn more about DME in the “Durable Medical Equipment” section of this guide.

 To receive home health care, a doctor must certify that the enrollee is homebound (cannot leave the house). Medicare pays for for following home health care services:

• Part-time/intermittent skilled nursing care
  • Unlike skilled nursing care provided in a skilled nursing facility, this type of care is given less than seven days per week and less than eight hours per day. 
• Physical, occupational and speech-language therapy
• Part-time/intermittent home health aide services
  • This type of care is personal, hands-on services such as help bathing, dressing and changing medical equipment or dressings.
• Medical social services
• Injectable osteoporosis drugs

Medicare will not pay for the following services provided at home:

• Round-the-clock (24/7) care
• Meal delivery services
• Homemaker services (when this is the only care the enrollee needs)
  • This means shopping, cooking and cleaning.
• Personal care (when this is the only care the enrollee needs)

If, while receiving home health care, the patient needs durable equipment such as a hospital bed or wheelchair that has been approved by Medicare, Medicare will pay 20% of the cost. 

Medicare Part B

Medicare Part B is a voluntary coverage option that covers medically necessary and preventative treatment as well as outpatient care in hospitals. Outpatient care refers to treatments and services that do not require patients to get admitted into a hospital. This type of coverage always requires the enrollee to pay monthly premiums. 

Part B coverage encompasses: 

• Clinical research
  • Diagnostic tests
  • Surgical treatment
  • Medicine
  • New types of patient care 
• Ambulance services
  • Ground ambulance transportation
  • Emergency air transportation
  • Medically necessary non-emergency ambulance transportation
• Durable medical equipment (DME)
  • Blood sugar monitors
  • Blood sugar test strips
  • Canes 
  • Commode chairs
  • Continuous passive motion devices 
  • Continuous Positive Airway Pressure (CPAP) devices
  • Crutches
  • Hospital beds
  • Infusion pumps and supplies
  • Lancet devices and lancets
  • Nebulizers and nebulizer medications
  • Oxygen equipment and accessories
  • Patient lifts 
  • Pressure-reducing support surfaces
  • Suction pumps
  • Traction equipment
  • Walkers
  • Wheelchairs and scooters
  • All other applicable equipment 
• Mental health care
  • Inpatient
  • Outpatient
    • One depression screening per year
    • Individual and group psychotherapy
    • Family counseling
    • Psychiatric evaluation
    • Medication management
    • Certain prescription drugs that are not self-administered
    • Diagnostic tests
    • A one-time “Welcome to Medicare” preventive visit
    • A yearly “Wellness” visit
  • Partial hospitalization
• Limited outpatient prescription drugs
  • Part B primarily covers drugs that are typically not self-administered. For instance, vaccinations, injections and intravenous medication.

Who can get Medicare Part B?

Eligibility for Part B Medicare coverage depends on whether an enrollee needs to pay Medicare Part A premiums. Learn more about Part A premiums, including who is required to pay them, in the “Medicare Part A” section of this guide.

Those who are not required to pay Part A premiums can get Part B as soon as they are entitled to Part A. Enrollment into Part B is automatic*. Enrollees can choose to keep or refuse Part B coverage. If they refuse coverage and choose to enroll at a later time, they may be subject to a late enrollment fee and are restricted to certain enrollment periods. Learn more about enrollment periods in the “When to Apply for Medicare” section.

*Enrollees living in Puerto Rico who have Part A coverage will not automatically be enrolled in Part B; they must actively enroll in Part B with the Application for Enrollment – Medicare Part B (https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS40B-E.pdf). 

Those who are required to pay premiums for Part A coverage must meet all of the following requirements to enroll in Medicare Part B: 

• Age 65 or older
• U.S. resident and a U.S. citizen or a legal alien who has been lawfully admitted for permanent residence and has been living in the U.S. for five continuous years prior to the month of applying to Medicare

Medicare Part B Expenses

All enrollees are required to pay the following fees for treatment under Medicare Part B.

Medicare Part B Premiums

Unlike Part A, all Medicare recipients must pay monthly premiums for Part B. Those who receive benefits checks through Social Security, the Railroad Retirement Board or the Office of Personnel Management will have their monthly premium payments automatically deducted from their check. All other enrollees will receive bills for premium payments. 

The standard 2024 monthly premium amount is $174.70. However, some enrollees with higher incomes may be required to pay higher monthly Part B premiums. This is based on the modified adjusted gross income, or MAGI. Your MAGI is calculated by finding your total income for the entire year and adding back any tax-exempt interest or deductions.

The table below outlines monthly premium amounts for enrollees with incomes higher than $103,000 (or $206,000 for joint tax returns) as shown on their income tax return documents two years prior to when they applied for Medicare. 

Individual Tax Return	Joint Tax Return	Married And Separate Tax Returns	Monthly Premium (2024)
$103,000 or less	$206,000 or less	$103,000 or less	$174.70
Between $103,000.01 and $129,000	Between $206,000.01 and $258,000	N/A	$244.60
Between $129,000.01 and $161,000	Between $258,000.01 and $322,000	N/A	$349.40
Between $161,000.01 and $193,000	Between $322,000.01 and $386,000	N/A	$454.20
Between $193,000.01 and $500,000	Between $386,000.01 and $750,000	Between $103,000.01 and $397,000	$559
$500,000.01 or more	$750,000.01 or more	$397,000.01 or more	$594

Deductibles and Coinsurance

Medicare Part B enrollees have an annual deductible, which is a set amount of money they pay out of pocket before Medicare pays. The annual deductible for 2024 is $240 per year. 

Once an enrollee meets this deductible, they are responsible for coinsurance, which is a percentage of healthcare costs that the enrollee pays. The current coinsurance amount is 20 percent. Medicare pays the remainder of the cost. Laboratory services, home health care and depression screening have no copay and are covered 100%.

Enrollees typically pay coinsurance for the following services:

• Doctor visits
• Outpatient therapy
• Durable medical equipment (DME)
  • Learn more in the “Durable Medical Equipment” section below.

Clinical Trials

Medicare enrollees can participate in clinical trials or research studies to test new equipment, medication or procedures. Patients must pay 20 percent of the Medicare-approved amount for all clinical trials in which they participate. Depending on the type of trial, the Part B deductible may also apply. 

Ambulance Services

Medicare Part B covers ambulance transportation to the nearest appropriate hospital, skilled nursing facility or critical access hospital. Medicare will only pay when the ambulance is used for medically necessary services and transportation in another vehicle (like a car) would endanger the health of the individual. 

Medicare may also pay for transportation via helicopter or airplane if ground transportation is not accessible or fast enough. Enrollees are required to pay 20 percent of the Medicare-approved amount for all types of ambulance services.

The Part B deductible also applies, which means if the enrollee has not met the annual deductible, he or she will pay out-of-pocket up to the annual deductible amount.

Durable Medical Equipment

Medicare enrollees can receive durable medical equipment (DME) that is medically necessary to treat their condition, illness or symptoms. DME must be prescribed by a doctor for use in the enrollee’s home. Examples of DME include: 

• Blood sugar monitors
• Blood sugar test strips
• Canes 
• Commode chairs
• Continuous passive motion devices 
• Continuous Positive Airway Pressure (CPAP) devices
• Crutches
• Hospital beds
• Infusion pumps and supplies
• Lancet devices and lancets
• Nebulizers and nebulizer medications
• Oxygen equipment and accessories
• Patient lifts 
• Pressure-reducing support surfaces
• Suction pumps
• Traction equipment
• Walkers
• Wheelchairs and scooters 

Medicare will only pay for DME if the enrollee’s doctor and equipment supplier participate in Medicare. If they do not participate, Medicare will deny the claim and the enrollee will be responsible for the full cost of the DME. Medicare-participating doctors and suppliers are contracted by Medicare to accept assignment, which means they can only charge enrollees coinsurance and the Part B deductible for the cost that is approved by Medicare. 

Enrollees pay a coinsurance of 20 percent for DME. They may apply their deductible to the payment. Enrollees may need to rent or buy the equipment, depending on the item and their medical needs. 

Limited Outpatient Prescription Drugs

Patients may need to pay 20 percent of the Medicare-approved amount for some medication received while at a doctor’s office. This includes drugs used in conjunction with DME, such as an infusion pump or nebulizer, some antigens, and injectable osteoporosis drugs. 

In a hospital outpatient setting, patients are charged a 20 percent copay for prescription drugs. If the patient’s hospital participates in the 340B Drug Pricing Program, he or she will be charged 20 percent of the lower price in most cases. The 340B program requires drug manufacturers who participate in Medicaid to sell outpatient drugs at discounted prices to healthcare organizations that primarily serve uninsured and low-income patients. Because health care organizations are receiving discounts, they can provide these drugs to patients at a lower cost.

Patients who receive drugs that are not covered by Medicare Part B must pay 100 percent of the drug cost unless they have prescription drug coverage through Medicare Part D or another plan. Learn more about Part D coverage in the “Medicare Part D” section of this guide. 

Outpatient Mental Health Care Service 

While Medicare Part A covers inpatient mental health care (care received while admitted into a hospital or psychiatric facility), Part B covers outpatient mental health services provided at doctors’ offices or other office settings outside of a hospital. Outpatient settings are those that do not require admissions or overnight stays. Coverage includes any services used to diagnose, treat or resolve mental health conditions. 

Medicare Part B covers the following outpatient mental health services:

• One free yearly depression screening provided by a primary care doctor
  • Medicare only pays when the doctor or health care facility participates in Medicare.
• Individual and group psychotherapy with a doctor or licensed therapist
  • Otherwise known as “talk therapy,” this service involves interacting with others in an effort to overcome obstacles and change certain behaviors.
• Family counseling
• Psychiatric evaluations and testing
• Medication management
• Some prescription drugs that are not “self-administered”
  • For example, drugs that need to be injected.
• Diagnostic tests
• Partial hospitalization
  • Unlike inpatient care, an overnight stay is not required. It is more intensive than standard outpatient care and is typically provided in outpatient wings at hospitals.
• Treatment for substance and alcohol abuse

Enrollees are required to pay 20 percent of the Medicare-approved amount for outpatient mental health services. They may apply their deductible to the payment.

Medicare Part C

Medicare Part C, also known as Medicare Advantage, is the option to receive Medicare coverage through a private insurance company. Part C (Medicare Advantage) plans are offered through private companies who have been approved by Medicare. These plans include all benefits that are offered in Plan A and Plan B, and frequently include Part D benefits as well. 

They may include greater coverage than standard Medicare offers, including vision, hearing and dental coverage. 

Like a standard health insurance plan, Medicare Part C recipients must stay within a plan’s network to receive benefits. In exchange, they receive more thorough coverage with a lower copayment than standard Medicare typically charges. 

Who can get Medicare Part C?

Individuals can typically enroll in a Medicare Part C plan if they:

• Have Medicare Part A and Part B.
• Are a U.S. citizen, U.S. national or are lawfully present in the U.S.
• Live in the health plan’s service area
  • Anyone interested in Medicare Part C must enroll in a plan that services their area of residence. 

Finding a Medicare Part C Plan

There are many different types of Medicare Part C plans available.

• Health Maintenance Organization (HMO) Plans — These plans provide coverage within the company’s network except in the case of emergencies. Typically, you must get a referral to see a specialist. If you see a doctor or practice outside of the network, you will pay a higher cost — in many cases, the full cost — compared to the in-network costs. 

• Preferred Provider Organization (PPO) Plans — Like HMO plans, PPO plans request that you stay in-network to receive coverage. However, you may still receive coverage for treatment outside of the network albeit with a higher cost to you. Referrals are not generally required to see a specialist. 
• Private Fee-For-Service (PFFS) Plans — PFFS plans are more similar to standard Medicare than other Medicare Advantage plans. You can seek treatment from any Medicare-approved provider that accepts the terms of the plan. Some PFFS plans have networks with lower costs, while others do not. In some cases, PFFS plans may not provide prescription drug coverage. You can enroll in Medicare Part D if your PFFS plan through Medicare Advantage does not include prescription coverage. 
• Special Needs Plan (SNP) — These plans are designed for Medicare recipients with specific illnesses or limited incomes. Like HMOs and PPOs, you are generally limited to receiving care within a network. You typically must have a primary care doctor or care coordinator to address treatment plans. SNPs must include Part D coverage. In order to qualify for an SNP, you should meet one of the following requirements:
  • You have a chronic illness
  • You live in an institution or need nursing care at home
  • You qualify for both Medicare and Medicaid
• Medicare Savings Account (MSA) Plans — MSA plans allow you to use a medical savings account combined with a high-deductible plan to receive coverage. If you use MSA, you generally must join a Part D plan as well, unless you already have a Medigap policy with drug coverage. 

The availability of Medicare Part C plans depends on the area in which you live. Some areas may offer all, some or none of these types of Part C plans. In addition, there may be several plans available in your area within the same category. Visit medicare.gov/plan-compare and enter your ZIP code to see the plans that are available in your area.

Medicare Part C Expenses

Medicare Part C expenses vary by plan. HMO, PPO, PFFS and SNP plans may charge a monthly premium. All plans will have different co-pays depending on the plan you select. 

In addition to the costs associated with your Part C plan, you are still required to pay your Part B premiums. Some Part C plans cover the cost of your Part B premiums or may charge a $0 premium. If you enroll in a MSA plan, you must also pay your Part B premium, but you will not be charged any additional premiums for your Part C plan.  No plan’s total annual out-of-pocket expenditures can exceed $7,550, not including prescription drug costs. However, many plans have a lower limit for out-of-pocket expenses.

Special Needs Plans (SNPs)

A Special Needs Plan (SNP) is a type of Medicare Part C plan that is limited to certain populations. These health care plans provide the same benefits and coverage options as Medicare Part C plans. Learn more about Part C plans in the “Medicare Part C” section of this guide.

Insurance companies can offer SNPs in one of the following categories:

1. Chronic SNP
2. Institutional SNP
3. Dual-Eligible SNP

What is a Chronic Special Needs Plan (SNP)?

A Chronic SNP is a plan that is designed for beneficiaries with specific chronic or disabling diseases. Since SNPs are provided through private insurance companies, providers may limit coverage to specific conditions. Beneficiaries should check to see if their condition falls under the SNP provider’s coverage requirements before enrolling. 

What is an Institutional Special Needs Plan (SNP)?

An Institutional SNP is a plan for beneficiaries who live in certain institutions, such as nursing homes. This type of plan is also open to individuals who require nursing home-level care at home. 

What is a Dual-Eligible Special Needs Plan (SNP)?

A Dual-Eligible SNP is a plan designed for beneficiaries who are eligible for both Medicare and Medicaid. 

Who is eligible for a Special Needs Plan (SNP)?

To qualify for a SNP, individuals must meet the following requirements:

• Have Medicare Parts A and B
• Live in the plan’s service area
• Meet the SNP’s requirements for Chronic, Institutional or Dual-Eligible plans

Medicare Part D

Medicare Part D, also known  as a “drug coverage plan,” provides prescription drug coverage that supplements Original Medicare (Parts A and B) plans. Because prescription drugs are not covered under Medicare Parts A or B, beneficiaries can choose to enroll in a Medicare Part D plan to be covered for a variety of prescription medications. Medicare Part D is not required; enrollees may choose to enroll in this type of plan if they do not have drug coverage from any other insurance plan.

Like Medicare Part C, drug coverage plans vary in availability based on the area in which an enrollee lives. Part D plans are offered by private insurance companies that work with Medicare to provide drug coverage to Medicare recipients. An enrollee’s insurance costs, drug costs and plan options vary depending on where he or she lives.

Although plans differ, all Medicare Part D insurance providers must meet certain drug class coverage options set by Medicare. This means that all plans must cover medications in the following drug classes: 

• Antidepressants
• Antipsychotics
• Anticonvulsants
• Cancer drugs
• HIV/AIDS drugs
• Immunosuppressants

Each Medicare Part D provider has its own drug formulary, or a list of prescription medications it will cover. Drugs in the formulary are typically divided into tiers based on cost and specialization. For example, a Part D plan may have a formulary that categorizes covered drugs into tiers based on generic medications, brand-name medications and specialized medications. In general, generic prescription drugs are the lowest-cost drug option in Part D plans. 

Medicare requires Part D plans to carry at least two versions of a drug in its formulary. This way, if a specific brand of drug is not available, a generic or other equivalent drug will be covered by the plan.

Who can get Medicare Part D?

Individuals who have Part A and/or Medicare Part B are typically eligible to enroll in Medicare Part D if they do not have prescription drug coverage through another plan. Beneficiaries who are enrolled in a Medicare Part C plan may already have prescription drug coverage incorporated into the plan, so it is important for enrollees to check their coverage policies before enrolling.

Medicare Part D Expenses

Medicare Part D recipients must pay a monthly premium for coverage. Premium amounts vary depending on the plan. Individuals with a higher income will have to pay an additional cost tied to their incomes in addition to the premium. This is called the Part D-Income Related Monthly Adjustment Amount.

If your income is more than the following amounts in 2024, you’ll generally need to pay the additional costs:

• More than $103,000 you file an individual tax return or are married and file separately
• More than $206,000 if you are married and file a joint tax return

The Social Security Administration (SSA) should notify you if you have to pay an extra amount because of your income.

Medigap Policies

Medigap policies are insurance policies designed to cover healthcare services and treatments not completely covered by standard Medicare. They can also cover expenses like copayments, coinsurance and deductibles. Medigap health insurance policies are offered by individual health insurance companies rather than the federal government.

Medigap Policy Requirements

Medigap policies are designed to supplement Medicare Part A and B coverage. In order to enroll in a Medigap health insurance plan, you must meet the following requirements:

• Have Medicare Parts A and B
  • You cannot enroll in a Medigap plan if you have Medicare Part C
• Pay the Medigap insurance provider a monthly premium
  • This premium is in addition to any premiums you pay for Medicare Part B coverage.
• Purchase a Medigap policy from a provider that is licensed in your state
  • Search for Medigap plans in your state using your ZIP code here: https://www.medicare.gov/medigap-supplemental-insurance-plans/#/m?year=2024&lang=en

Medigap policies can only be assigned to one person. There are no group, family or spousal Medigap plans. If a married couple wishes to have Medigap coverage for both spouses, each individual must purchase his or her own policy.

Medigap policies cannot be used with Medicare Part C plans. They cannot be used to pay your Part C copayments, deductibles or premiums. It is illegal for any insurance provider to sell you a Medigap policy when you have a Medicare Part C plan. 

Medigap insurance plans do not include prescription drug coverage*. If you want or need drug coverage, you can purchase a separate Medicare Part D plan. Refer to the “Medicare Part D” section of this guide for more information about drug coverage options.

*Some Medigap policies sold before January 1, 2006 include prescription drug coverage, but all policies sold thereafter do not.

Medigap policies are standardized. This means it is easier to compare plans from different insurance companies because they all offer the same basic benefits. For example, two different health insurance providers selling the same Medigap policy are required to provide the same benefits.  However, the costs can vary between companies for the same policies. 

Comparing Medigap Policies

In all states except Massachusetts, Minnesota and Wisconsin, Medigap policies are standardized the same way. Like Medicare plans, Medigap policies are also categorized by letter. The following Medigap plans are available: 

The differences between these Medigap plans are in the deductibles, copays, and whether they cover skilled nursing facilities. Each insurance company is responsible for determining which type of Medigap plan(s) it wants to sell. All insurance providers must adhere to the following requirements when selling Medigap policies:

• Companies do not need to offer every Medigap plan.
• Companies must offer Medigap Plan A if they offer any Medigap policy.
  • If they offer any plan in addition to Medigap Plan A, they must also offer Plans C or F. 

*If they offer any plan in addition to Medigap Plan A, they must also offer Plans C or F. 

Medigap Benefits by Policy

Medigap policies are categorized into 10 plans, each of which offers different benefits to Medicare recipients. The table below shows the benefits provided by each type of Medigap plan in all states except Massachusetts, Minnesota and Wisconsin. For information about Medigap policies in these states, refer to the “Medigap Policies in Massachusetts, Minnesota and Wisconsin” section of this guide.

• “Y” indicates the plan covers the benefit completely.
• “N” indicates the plan does not cover the benefit.
• A percentage “%” indicates the plan covers the corresponding benefit by the percentage listed.
• “N/A” indicates it does not apply for this benefit.

• One asterisk (*) indicates that the policy offers a high-deductible plan option in some states. With this option, beneficiaries must pay for Medicare-covered costs (coinsurance, copayments and deductibles) up to the deductible amount of $2,800 in 2024 before the Medigap policy pays anything.
• Two asterisks (**) indicates that the plan pays 100 percent of the costs of covered services for the rest of the year after beneficiaries meet their out-of-pocket yearly limit and the yearly Medicare Part B deductible.
• Three asterisks (***) indicates that the plan pays 100 percent of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that do not result in inpatient admission. 

Medigap Benefits	Medigap Plans	colspan	colspan	colspan	colspan	colspan	colspan	colspan	colspan	colspan
	A	B	C	D	F*	G*	K	L	M	N
Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Part A hospice care coinsurance or copayment	Y	Y	Y	Y	Y	Y	50%	75%	Y	Y
Part A deductible	N	Y	Y	Y	Y	Y	50%	75%	50%	Y
Part B coinsurance or copayment	Y	Y	Y	Y	Y	Y	50%	75%	Y	Y***
Part B deductible	N	N	Y	N	Y	N	N	N	N	N
Part B excess charges	N	N	N	N	Y	Y	N	N	N	N
Blood transfusions per year (first 3 pints)	Y	Y	Y	Y	Y	Y	50%	75%	Y	Y
Skilled nursing facility care coinsurance	N	N	Y	Y	Y	Y	50%	75%	Y	Y
Foreign travel exchange	N	N	80%	80%	80%	80%	N	N	80%	80%
Out-of-pocket limit for 2024**	N/A	N/A	N/A	N/A	N/A	N/A	$7,060	$3,530	N/A	N/A

Medigap Policies in Massachusetts, Minnesota, and Wisconsin 

In Massachusetts, Minnesota and Wisconsin, Medigap policies are standardized in a different way. Continue reading the sections below to learn more about Medigap in these three states.

Medigap Policies in Massachusetts

All Massachusetts Medigap policies must cover the following basic benefits: 

• Part A coinsurance
• Part A hospice cost sharing
  • Provides gap coverage for some Medicare Part A enrollees who are required to pay for hospice care or services.
• 365 days of additional Part A hospital coverage after Part A Medicare coverage ends
• Part B coinsurance
• First 3 pints of blood for transfusions per year

Beneficiaries in Massachusetts can choose from three types of Medigap plans:

• Core Plan
• Supplement 1 Plan
• Supplement 1A Plan

Core Plan

The core plan covers the following: 

• All basic benefits described above
• 60 inpatient days in a mental health treatment facility per year
• State-mandated benefits (yearly pap smears and mammograms)

Supplement 1 Plan

The Supplement 1 Plan covers everything that the Core Plan covers in addition to the following:

• Part A inpatient hospital deductible
• Part A skilled nursing facility coinsurance
• Part B deductible
• Foreign travel emergency costs
• 120 inpatient days for mental health treatment per year

Supplement 1A Plan

The Supplement 1 Plan is not available to newly-eligible Medicare patients. Only those who enrolled in Medicare prior to January 1, 2020 are eligible for this plan. It covers everything that the Core Plan covers in addition to the following:

• Part A inpatient hospital deductible
• Part A skilled nursing facility coinsurance
• Foreign travel emergency costs
• 120 inpatient days for mental health treatment per year

Medigap Policies in Minnesota

All Minnesota Medigap policies must cover the following basic benefits: 

• Part A coinsurance
• Part B coinsurance
• Part A hospice care cost sharing
  • Provides gap coverage for some Medicare Part A enrollees who are required to pay for hospice care or services
• Parts A and B home health services and supplies cost sharing
• First 3 pints of blood for transfusions per year

There are two plans in Minnesota

• Basic Plan
• Extended Basic Plan

Basic Plan

The Basic Plan covers the following:

• All basic benefits described above
• Part A skilled nursing facility (SNF) coinsurance
  • Provides 100 days of care in a SNF
• 80 percent of foreign travel emergency
• 50 percent of outpatient mental health care costs
• Medicare-covered preventive care
• 20 percent of physical therapy costs
• State-mandated benefits (diabetic equipment and supplies, routine cancer screening, reconstructive surgery, immunizations)

Extended Basic Plan

The extended basic plan covers: 

• All basic benefits described above
• Part A inpatient hospital deductible
• Part A skilled nursing facility (SNF) coinsurance
  • Provides 120 days of care in a SNF
• Part B deductible
  • Except newly-eligible Medicare recipients. As of January 1, 2020, anyone who is new to Medicare cannot have the Part B deductible covered by Medigap. 
• 80 percent of costs associated with a foreign travel emergency**
• 50 percent of outpatient mental health
• 80 percent of usual and customary fees**
• Medicare-covered preventive services
• 20 percent of physical therapy
• State-mandated benefits (diabetic equipment and supplies, routine cancer screening, reconstructive surgery, immunizations)

Medigap Policies in Wisconsin

All Wisconsin Medigap policies must cover the following basic benefits: 

• Part A inpatient hospital coinsurance
• Part A hospice cost-sharing
  • Provides gap coverage for some Medicare Part A enrollees who are required to pay for hospice care or services
• Part B coinsurance
• First 3 pints of blood for transfusions per year

Wisconsin has one type of Medigap plan known as the Basic Plan. However, insurance companies have more flexibility in defining the Basic Plan. They can choose to add on certain benefits to the standard coverage options. All companies offering the Basic Plan cover the following:

• All basic benefits described above
• Part A skilled nursing facility (SNF) coinsurance
• 175 days of inpatient mental health care after the Medicare inpatient mental health care limit is reached
• 40 home health care visits in addition to the Medicare allowed number of visits
• State-mandated benefits

Wisconsin has other Medigap plan options that vary in cost and benefits. The 50% and 25% cost-sharing plans are similar to standardized Medigap Plans K and L, which are outlined in the table found in the “Medigap Benefits by Policy” section of this guide. Insurance companies can offer Medigap Basic plans with a high deductible of $2,800 in 2024. Additionally, companies also have the option to include the following benefits in their Medigap policies: 

• 50% Part A deductible
• Part B deductible
  • Except newly-eligible Medicare recipients. As of January 1, 2020, anyone who is new to Medicare cannot have the Part B deductible covered by Medigap. 
• Part B copayment or coinsurance 
• Part B excess charges
• Additional home health care
  • Provides 365 visits, including those paid by Medicare
• Expenses related to a foreign travel emergency

Program of All-Inclusive Care for the Elderly (PACE)

PACE is a joint Medicare and Medicaid program that helps elderly individuals seek medical care in their communities, rather than requiring them to go to a nursing home or other long-term care facility. Enrollees will receive a team of health care professionals dedicated to coordinating their treatment. 

PACE covers all treatments covered by Medicare and Medicaid that are deemed medically necessary by your team of health care professionals. These include:

Because it is not a federal program, PACE is not available in all states. Instead, individual PACE programs are available to serve limited areas. There are currently 146 PACE programs with 273 centers across 32 states. 

Currently, a PACE program is only available in Washington, D.C. and the following states: 

Because PACE programs are location-specific, you may not have access to a program, even if it is available in your state. 

Use the PACE program locator tool to see if there is a PACE program near you: https://www.npaonline.org/pace-you/pacefinder-find-pace-program-your-neighborhood 

Who is eligible for PACE?

In order to be eligible for PACE, you must meet the following requirements: 

• Be 55 years of age or older
• Live within the service area of a PACE organization
• Require a nursing home level of care, as certified by your state
• Be able to live in your community with PACE care

PACE Expenses

The costs associated with PACE vary by program. Additionally, your expenses depend on whether you qualify for Medicare, Medicaid or both. There are no deductibles or copayments for PACE treatment approved by your health team.

• If you are eligible for just Medicare alone, you will need to pay premiums for long-term care in addition to a prescription drug (Part D) premium. 
• If you are eligible for Medicare and Medicaid, you will not be charged a premium for the long-term care portion of PACE. 
• If you are not eligible for Medicare or Medicaid, you are responsible for the costs of all PACE treatment.

How to Pay for Medicare 

You must pay premiums for Medicare coverage, along with deductibles, copayments and coinsurance when you seek specific treatments. 

• A premium is a payment made by an insured individual in exchange for having coverage.
• A deductible is the amount of money an enrollee pays out-of-pocket for covered services before Medicare begins to pay.
• A copayment is a fixed cost that the enrollee pays out of pocket for services, office visits or medications.
• Coinsurance refers to the enrollee’s shared expense of a covered service. It is an agreed-upon amount of money an enrollee pays out-of-pocket; the remaining cost is paid by Medicare.

Paying for Medicare Parts A and B

You will be required to pay premiums for Medicare Part B and D, and may need to pay premiums for Medicare Part C depending on your specific plan. You may also have to pay premiums for Medicare Part A as well, depending on your work history. Refer to “Who needs to pay Medicare Part A premiums?” for more information.

If you receive Social Security or Railroad Retirement Board benefits, your Medicare Part B premiums can be automatically deducted from your Social Security payments.

There are four options for paying your Medicare Parts A and B premiums:

1. Log in to your Medicare account and pay your premiums manually using a credit card, debit card or bank account. Log in here: https://account.mymedicare.gov/ 
2. Set up an online bill payment service from your checking or savings account through your bank. Follow your bank’s instructions for setting up this automatic payment. You must provide your Medicare number and list the payee as “CMS Medicare Insurance,” and the address as: 
   Medicare Premium Collection Center
   P.O. Box 979098
   St. Louis, MO 63197-9000

3. Sign up for Medicare Easy Pay, which automatically deducts the premiums from your checking or savings account monthly. To sign up for Easy Pay, you must fill out the following form https://www.cms.gov/medicare/cms-forms/cms-forms/downloads/sf5510english.pdf. Mail the form to the Medicare office:
   Medicare Premium Collection Center
   P.O. Box 979098
   St. Louis, MO 63197-9000

4. Mail your payment to Medicare by credit card, debit card, check or mail order. Use the payment coupon that comes with your bill to send this payment, and mail the completed coupon to:
   Medicare Premium Collection Center
   P.O. Box 979098
   St. Louis, MO 63197-9000

Paying for Medicare Part C

If your Medicare Part C plan requires premiums, you will pay the insurance provider directly. During enrollment, you may be able to elect your preferred payment method. The ways in which you can pay your premiums vary depending on your insurance provider, but most providers offer one or more of the following options:

1. Pay with a check
   • When you receive a bill from your Part C provider, mail a check for your premium payment to the address listed.
2. Pay automatically through debit
   • Set up automatic payments with your bank or credit union. Your provider will deduct the premium payment automatically.
3. Pay with a debit or credit card
   • Enter your debit or credit card information on your provider’s website, or follow payment instructions in your premium bill.
4. Have payments deducted from benefits
   • Some providers may allow you to have your Part C premium deducted from other benefits you receive through Social Security or the Railroad Retirement Board (RRB).

The payment methods listed above may not be available with your Part C plan provider. Contact your provider to learn more about how to submit payments. 

Paying for Medicare Part D

You can have Part D premiums deducted directly from your Social Security benefits. However, you must contact your Part D provider, not Medicare or Social Security, to set up the automatic deductions. 

Aside from having the cost deducted from your premium, your Part D provider will offer options for you to pay the monthly premium. 

If you must pay a Part D IRMAA payment, you should pay this directly to Social Security. Your options for paying this are the same as your options for paying Medicare Parts A and B premiums, which you can learn about in the section above.

Paying for a Medigap Plan

Like Medicare Part C, payment methods for Medigap plans vary depending on your insurance provider. If you are required to pay a premium, you will pay the provider directly. Refer to the “Paying for Medicare Part C” section for a list of common payment methods that your provider may allow. Contact your provider to learn more about how to submit payments. 

The Medicare Savings Program

Your state can provide you with assistance for Medicare premiums and costs if you are a low-income resident and meet specific qualifications. Depending on the assistance for which you qualify, you can also receive help paying your deductibles and copayments for Medicare Parts A and B. 

The following programs are available for low-income Medicare recipients. Please note that the information below is current as of 2023; information for 2024 has not yet been made available.

• Qualified Medicare Beneficiary (QMB) Program 
  • Individual Monthly Income Limit: $1,153
  • Married Couple Monthly Income Limit: $1,546
  • Individual Resource Limit: $8,400
  • Married Couple Resource Limit: $12,600
  • Program helps pay for:
    • Part A premiums
    • Part B premiums
    • Deductibles, coinsurance, and copayments
• Specified Low-Income Medicare Beneficiary (SLMB) Program — This program provides assistance for low-income individuals who have Part A as well as limited income and resources.
  • Individual Monthly Income Limit: $1,379
  • Married Couple Monthly Income Limit: $1,851
  • Individual Resource Limit: $8,400
  • Married Couple Resource Limit: $12,600
  • Program helps pay for:
    • Part B premiums
• Qualifying Individual (QI) Program — This program is similar in purpose to the SLMB program. However, it is granted on a first-come, first-serve basis and priority is given to those who received QI benefits the previous year. This program is not available to Medicaid recipients.
  • Individual Monthly Income Limit: $1,549
  • Married Couple Monthly Income Limit: $2,080
  • Individual Resource Limit: $8,400
  • Married Couple Resource Limit: $12,600
  • Program helps pay for:
    • Part B premiums
• Qualified Disabled and Working Individuals (QDWI) Program — This program helps pay for Part A premiums for any of the following:
  • Working disabled persons under 65
  • Individuals who lost premium-free Part A when they returned to work
  • Individuals who are not getting medical assistance from the state
  • Individuals who meet the state income and resource limits  
  • Limits:
    • Individual Monthly Income Limit: $4,615
    • Married Couple Monthly Income Limit: $6,189
    • Individual Resource Limit: $4,000
    • Married Couple Resource Limit: $6,000
    • Program helps pay for:
      • Part A premiums

How to Apply for Medicare

There are three ways to enroll in Medicare:

• Online
• By phone
• In person

Depending on the type of Medicare plan in which you want to enroll, you may only be able to enroll in some of the ways listed above. Enrollment into Medicare can either be automatic or manual. Your method of enrollment depends on the following factors:

• If you are receiving benefits from Social Security or the Railroad Retirement Board (RRB) at least four months before turning 65
• If you are younger than 65 with a disability
• If you have End Stage Renal Disease (ESRD)
• If you have ALS (Lou Gherig’s Disease)

Continue reading the sections below to learn more about how to apply for Medicare, including your enrollment options and when you are eligible to apply for benefits. 

Information and Documents Needed to Apply

During the Medicare application process, you will need to provide certain information and documents that verify your eligibility for the program. 

To apply for Medicare Parts A and B, you will need to provide the following information:

• Your date and place of birth
• Your Medicaid number and start date, if applicable
• Your current health insurance information

If you are applying for Medicare Parts A or B as a spouse of someone eligible for Medicare, you will also need to provide the following information:

• Your marriage and divorce information
  • Name of current spouse
  • Name of previous spouse, if previous marriage lasted for more than 10 years or ended in death
  • Spouse’s or spouses’ date(s) of birth and SSN(s)
  • Beginning and end date(s) of marriage(s)
  • Place(s) of marriage(s)
• Names and dates of birth of children who became disabled before the age of 22, who are under 18 and unmarried or who are 18 or 19 and attending school full time
• U.S. military service history, including:
  • Branch served in
  • Position held
  • Start and end dates
• Employer details for last three years, if not self-employed
  • Employer name
  • Start and end dates
• Self-employment details for last three years, if self-employed
  • Business type
  • Total net income
• Bank account information for direct deposit

To apply for Medicare Parts C or D, you will need to provide the following information found on your Medicare card:

• Your Medicare number
• The date(s) that your Medicare Parts A and/or B coverage began 

How to Apply for Medicare Parts A and B

You can apply for Medicare Parts A or B in the following ways:

• Online
• By phone
• In person

Apply Online for Parts A and B

Follow the steps outlined below to apply online:

1. Visit the Social Security website here: https://www.socialsecurity.gov/medicare/apply.html
2. Scroll down and select “Apply for Medicare Only.”
   • The link will bring you to the “Apply for Benefits” online portal on the Social Security website.
3. Enter all required information.
   • Refer to the “Information and Documents Needed to Apply” section for a complete list.
   • The application may take between 10 and 30 minutes.
4. Click “Submit Now.” 

Once you submit the form, you will receive a receipt and an application number which you should keep for future reference. The Social Security Administration (SSA) will process your application and mail you their decision. 

Apply by Phone for Parts A and B

Enroll in Medicare Parts A and B by calling 1-800-772-1213. 

Apply in Person for Parts A and B

Enroll in Medicare Parts A and B by visiting your local Social Security office. Search for an office near you using the locator tool here: https://secure.ssa.gov/ICON/main.jsp 

What if I refused Part B coverage at first, but want to apply now?

If you refused Part B coverage when you first became eligible and would like to apply for coverage now, you can enroll in the following ways:

• Online
  • Log into your mySocialSecurity account here: https://www.ssa.gov/myaccount/
  • Complete the online application and click “submit”
• By mail
  • Download, print and complete the “Application For Enrollment in Medicare Part B” (https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS40B-E.pdf ) and mail it to your local Social Security office. Find an office near you here: https://secure.ssa.gov/ICON/main.jsp 

How to Apply for Medicare Part C

Since Medicare Part C plans are offered by private insurance companies rather than the federal government, the ways you can enroll may differ. Depending on your provider, you may be able to enroll in the following ways:

• Online
  • Visit your provider’s website to see if there is an online application available.
• By phone
  • Call your provider directly to apply or learn more about your application options.
  • Call the national Medicare line at 1-800-633-4227. 
• By mail or in person
  • All Medicare Part C plans must offer a paper enrollment form. Some providers may allow for mail-in applications while others require you to return the forms in person. Contact your plan for more information. 

To enroll in a Medicare Part C plan, you must first find a plan that is available in your area. Use the plan finder here:https://www.medicare.gov/plan-compare/ 

How to Apply for Medicare Part D

Before enrolling in a Medicare Part D plan, you must find a plan that is available in your area. Use the plan finder here: https://www.medicare.gov/plan-compare/. Once you find a Part D plan that works for you, you can enroll in the following ways:

• Online
  • Apply on your provider’s website or directly on the Medicare.gov website here: https://www.medicare.gov/plan-compare
• By phone
  • Call your provider directly to apply or learn more about your application options.
  • Call the national Medicare line at 1-800-633-4227. 
• By mail or in person.

All Medicare Part D plans must offer a paper enrollment form. Some providers may allow for mail-in applications while others require you to return the forms in person. Contact your plan for more information.

How to Apply for a Medigap Plan

If you want to enroll in a Medigap program, you must first compare your options in your state. Once you know which Medigap plan you want to enroll in, find an insurance company in your state that offers that policy. You can use any of the following methods to find insurers: 

• Visit the following link and type in your ZIP code: https://www.medicare.gov/medigap-supplemental-insurance-plans/ 
• Contact your State Insurance Department for assistance: https://www.medicare.gov/Contacts/#resources/sids 
• Search online for information about insurance companies that offer Medigap in your area.

Once you have located a Medigap policy you want to sign up for, follow the steps provided by the insurer to enroll. 

How to Apply to the Program of All-Inclusive Care for the Elderly (PACE)

Because PACE programs operate individually, the application process varies by state and specific plan. For information on how to apply, visit the PACE plan website that serves your location or call your area’s PACE plan directly.

You can search for a PACE program in your area here to find contact information: https://www.npaonline.org/pace-you/pacefinder-find-pace-program-your-neighborhood.

When to Apply for Medicare

You can only apply to Medicare during certain windows of time throughout the year called enrollment periods. There are three types of enrollment periods available to Medicare applicants:

1. Initial Enrollment Period (IEP)
2. Special Enrollment Period (SEP)
3. General Enrollment Period (GEP)

If you do not apply for Medicare Parts A, B or D coverage when you first become eligible, you may be charged a late enrollment fee when you apply for coverage at a later time. Learn more about late enrollment fees in the section called “Penalties for Missing Medicare Enrollment Deadlines” of this guide.

Initial Enrollment Period

The Initial Enrollment Period (IEP) applies to anyone who is newly eligible for Medicare based on their age or disability status. It includes the seven months surrounding the applicant’s 65th birthday (if eligibility is based on age) OR the 24 months during which the applicant receives Social Security or Railroad Retirement Board (RRB) benefits (if eligibility is based on disability status). 

The IEP is split into three periods:

• 3 months before the month the applicant turns 65 OR the month before the 25th month of receiving Social Security or RRB disability benefits
• The month of the applicant’s 65th birthday OR the 25th month of receiving Social Security or RRB disability benefits
• The three months after the month the applicant turns 65 OR after the 25th month of receiving Social Security or RRB disability benefits

Applicants can apply for the following types of Medicare in their Initial Enrollment Period:

• Medicare Part A
• Medicare Part B
• Medicare Part C
• Medicare Part D

General Enrollment Period

Applicants who did not apply for Medicare Parts A and B during the Initial Enrollment Period (IEP) can enroll for these types of coverages during the General Enrollment Period (GEP), which takes place January 1 to March 31 every year. They may only enroll in Medicare during the GEP if:

• They have missed their Initial Enrollment Period; AND
• They do not qualify for a Special Enrollment Period (SEP).
  • Learn more about what qualifies for a Special Enrollment Period in the next section.

If an applicant applies for Medicare Parts A or B during the General Enrollment Period, he or she may be charged higher premiums for missing initial enrollment. Learn more about late enrollment penalties in the section “Penalties for Missing Medicare Enrollment Deadlines” of this guide.

Open Enrollment Period –  Medicare Parts C and D 

Applicants who did not enroll in Medicare Parts C or D during their Initial Enrollment Periods cannot enroll for the first time during the General Enrollment Period of January 1 to March 31 (unless they already have Medicare Part C and want to switch back to Parts A and/or B). Instead, they must wait until the Open Enrollment Period, which takes place October 15 to December 7 every year. 

Applicants who enroll in a Medicare Part D plan during this Open Enrollment Period may be charged a late enrollment penalty.  Learn more about late enrollment penalties in the section “Penalties for Missing Medicare Enrollment Deadlines” of this guide. 

Special Enrollment Period (SEP)

Applicants may be able to enroll in Medicare outside of their Initial Enrollment Period without being penalized during a Special Enrollment Period (SEP). The goal of this period is to allow individuals who are eligible for Medicare to enroll as soon as their other health coverage ends so that there is no gap in coverage. 

SEP Based on Current Employment

Many individuals choose to delay Medicare enrollment because they are (or their spouse) working and are already covered through an employer-sponsored (otherwise known as group) health insurance plan. These individuals are eligible to enroll in Medicare anytime as long as they are at least 65 years of age and:

• They or their spouse is working, AND
• They are covered by a group health plan through that job. 

For purposes of the Special Enrollment Period, COBRA and retiree health plans do not count as a group health care plan. 

Coverage for applicants who enroll in Medicare while they are still in a group health plan will begin on the first day of the month they enroll. Or, if they so choose, coverage can begin on the first day of any of the following three months.

SEP Based on Recent Employment

Individuals who are not currently working can still sign up for Medicare outside of their Initial Enrollment Period during an eight-month Special Enrollment Period. This period begins when one of the following occurs (whichever comes first): 

• The month after employment ends
• The month after the group health plan ends

SEP Based on Volunteer Work

Volunteers who are serving in a foreign country can qualify for a Special Enrollment Period of six months. They must meet the below requirements: 

• The volunteer serves outside the U.S. via a program that meets these criteria:
  • The program takes place across a 12-month period at minimum
  • The program is sponsored by an organization that is exempt from taxation
• The volunteer has or did have health insurance coverage during the period while he or she was away during the volunteer service.

Learn more about this SEP here: https://secure.ssa.gov/apps10/poms.nsf/lnx/0600805350.

Automatic Eligibility

Enrollment into Medicare Parts A and B is automatic for individuals who meet the following criteria: 

• Receive Social Security or Railroad Retirement Board (RRB) benefits at least four months before turning 65
  • Individuals will receive a Medicare card in the mail approximately three months before their 65th birthday.
• Receive disability benefits from Social Security or the RRB for 24 months
  • Individuals will receive a Medicare card in the mail approximately three months before their 25th month of receiving disability benefits. 

When to Enroll in a Medigap Policy

The Medigap enrollment period begins six months immediately after a beneficiary enrolls in Medicare Part B coverage upon turning 65. For example, if the beneficiary enrolls in Medicare coverage in June, the Medigap open enrollment period is between June and November.

Insurance providers are not federally required to offer Medigap policies to individuals younger than 65, but some states have instituted a state law that requires such an action. Even if a beneficiary who is younger than 65 has Medicare coverage, he or she may not be able to enroll in a Medigap policy based on state law.

The following states require insurers to offer at least one Medigap policy to individuals younger than 65: 

The following states do not require insurers to carry a Medigap policy for individuals younger than 65: 

Penalties for Missing Medicare Enrollment Deadlines

Part A Deadlines

Those who do not enroll in Medicare Part A during their Initial Enrollment Period (IEP) will face an enrollment penalty only if they are required to pay Part A Premiums. Refer to the “Medicare Part A Premiums” section to learn more about who is required to pay premiums. 

The penalty for missing Part A enrollment is paying a higher premium. Beneficiaries will see their Part A premiums increase by 10 percent for twice the number of years they could have had Medicare, but did not. 

For example, a beneficiary who delayed Part A enrollment for two years, and who is required to pay a $458 Part A premium based on his or her work credits, will pay $503.80 ($458 + $45.80 in the 10 percent penalty) for a period of four years (two years of delayed enrollment multiplied by the required two year calculation). 

Part B Deadlines

Those who do not enroll in Part B during their Initial Enrollment Period (IEP) will be charged an enrollment penalty when they choose to sign up for Part B coverage. The penalty results in higher premiums, which increase by 10 percent for each 12-month period after the IEP that they do not enroll in Part B coverage. 

For example, a beneficiary who delayed Part B enrollment for a period of 27 months would need to pay a premium that is 20 percent higher. So, if the beneficiary is required to pay a $170.10 Part B premium, he or she will instead pay a premium of $204.12 ($170.10 + $34.02 in the 20 percent penalty). This penalty is enforced for as long as the individual has Part B coverage. 

Part C Deadlines

There is no late enrollment penalty for Medicare Part C. Individuals who miss their Initial Enrollment Period must wait for the Open Enrollment Period, which takes place between October 15 and December 7 of each year. 

Part D Deadlines

Those who do not enroll in a Medicare Part D plan during their Initial Enrollment Period (IEP) will be charged an enrollment penalty when they choose to sign up for Part D coverage unless they have comparable drug coverage or qualify for Extra Help (financial assistance for drug costs). The penalty results in higher premiums, which increase for each month in which beneficiaries do not enroll in Part D while eligible.

The penalty is calculated by multiplying 1 percent of the national base beneficiary premium, which is the national average amount that insurance companies charge in prescription drug plans, times the number of complete months the beneficiary did not enroll in Part D while eligible and rounded to the nearest $.10.

The 2024 national base beneficiary premium is $34.70. So, a beneficiary who delayed Part D coverage for a period of 10 months would need to pay a premium of $38.20 ($34.70 x 1% x 10  =$3.470 → rounded to the nearest $.10 = $3.50 + $34.70 = $38.20). The penalty is enforced for as long as the individual has Part D coverage.

When to Make Changes to a Medicare Plan

Individuals who already have Medicare coverage can make changes during the following periods:

• General Enrollment Period (January 1 – March 31)
• Open Enrollment Period (October 15 – December 7)

Beneficiaries may perform the following actions during the General Enrollment Period:

• Switch from one Medicare Part C plan to another
  • Including choosing a Medicare Part C plan with drug coverage
• Unenroll from a Medicare Part C plan and return to Medicare Parts A and/or B with the added benefit of enrolling in a Medicare Part D plan simultaneously
• Return to Medicare Parts A and/or B within the first 3 months of having Medicare
  • This is only applicable to those who first enrolled in coverage during their IEP

Beneficiaries may perform the following actions during the Open Enrollment Period:

• Change from Medicare Parts A and/or B (with or without a Medicare Prescription Drug Plan) to Medicare Part C
• Change from Medicare Part C back to Medicare Parts A and/or B (with or without a Medicare drug plan)
• Switch from one Medicare Part C plan to another
  • Including choosing a Medicare Part C plan with drug coverage
• Switch from a Medicare Part D plan to another
• Disenroll from Medicare Part D coverage completely

After Enrolling in Medicare

Medicare Card

When you enroll in Medicare, you receive a card in the mail documenting your enrollment. If you are automatically enrolled in Medicare, whether by meeting the age qualifications or disability benefit qualifications, you will receive the card in the mail three months before you become eligible. 

You receive different cards for Medicare Parts A and B, Part C and Part D. It is important to carry and provide all cards depending on what coverage you are seeking. 

What is a Medicare card?

Like an insurance card, a Medicare card provides proof of enrollment and coverage. It contains your name, your Medicare ID number, which allows providers to confirm your identity and enrollment, whether your coverage includes Parts A and B, and the date that coverage began. 

How to Use the Medicare Card

When you seek coverage for any treatment through Medicare, present the card as you would a proof of insurance card. 

Replacing a Medicare Card

If you lose or damage your Medicare card, you can replace it. Although your doctor can look up your Medicare ID number online, providing the card in person can help you seek treatment without delays. 

If your card is lost or damaged, you can request a replacement by signing in to your account at https://www.mymedicare.gov/ and printing out a new copy. Medicare cards are printed on paper, and do not have any special requirements to be reprinted. 

If you believe your card has been stolen and your Medicare ID number may be used fraudulently, call 1-800-633-4227 to request a change. TTY users should contact 1-877-486-2048. 

Medicare Coverage Start Dates

The date your coverage begins depends on when you chose to enroll in a Medicare plan. Continue reading the sections below to learn about coverage start dates for all Medicare plans. 

Medicare Parts A and B

If you are automatically eligible for Medicare Parts A and B, coverage begins one month before your birthday. For example, if your birthday is August 17, your coverage begins July 17. To see if you qualify for automatic eligibility for Medicare Parts A and B, refer to the “Automatic Eligibility” section of this guide. 

If you do not qualify for automatic enrollment and choose to sign up for Medicare Parts A and/or B during your Initial Enrollment Period (IEP), the coverage start dates are as follows: 

• If you enroll in the three months before your birth month, your coverage begins one month before your birthday. 
• If you enroll during your birth month, your coverage begins one month after you enroll. 
• If you enroll the month after your birth month, your coverage begins two months after you enroll. 
• If you enroll two or three months after your birth month, your coverage begins three months after you enroll.

If you enroll during the General Enrollment Period (GEP), your coverage begins July 1. 

Medicare Part C

The coverage start dates for Medicare Part C depend on when you enroll in a plan. 

• If you enroll in a Medicare Part C plan in any of the three months before you turn 65 or before you reach your 25th month of disability benefits, your coverage begins the first day of the month you turn 65 or the 25th month of benefits.
• If you enroll in a Part C plan during the month you turn 65 or during your 25th month of disability benefits, coverage begins the first day of the following month.
• If you enroll in a Part C plan in any of the three months after you turn 65 or after you reach your 25th month of disability benefits, coverage begins the first day of the following month. 
• If you enroll in a Part C plan during the Open Enrollment Period (October 15 – December 7), coverage begins January 1 of the following year. 

Medicare Part D

The date your Medicare Part D coverage begins also depends on when you chose to enroll in a plan. 

• If you enroll in any of the three months before you turn 65 or before you reach your 25th month of disability benefits, coverage begins the first day of the month you turn 65 or the 25th month of benefits. 
• If you enroll in a Part D plan during the month you turn 65 or during your 25th month of disability benefits, coverage begins the first day of the following month.
• If you enroll in a Part D plan in any of the three months after you turn 65 or after you reach your 25th month of disability benefits, coverage begins the first day of the following month. 

Finding Approved Medicare Providers

In order to receive your Medicare benefits, you must go to a provider that accepts Medicare. Unlike traditional health insurance plans, this is typically the case in most places in the United States, unless you have a Medicare Part C plan. 

If you have Original Medicare (Parts A and B), you can find Medicare providers through Medicare’s Physician Compare website here: https://www.medicare.gov/care-compare/.

Specify the type of provider you are looking for. You can also search by name, body part you want treatment for, condition you want treatment for and more. 

Medicare Claims

Typically, your health care provider will file a claim on your behalf when you seek treatment. A claim is essentially a request to your insurance provider to pay for your medical care. You only need to file a claim if your doctor has failed to file a claim promptly and you believe he or she will miss the deadline to file the claim. 

Claims must be filed within 12 months, or one calendar year, of the date a service was provided. If your doctor has not filed a claim and the deadline is approaching, you should file the claim yourself.

You will need the following to file a claim: 

• The completed claim form
• The itemized bill from your provider
• A letter explaining your reason for filing the claim
• Any other supporting documents for your claim

You can find the claim form here: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1490s-english.pdf.

Log into your myMedicare account (https://account.mymedicare.gov) and check your Medicare Summary Notice to see the address to where you should send the claim and supporting documents.

What is a Medicare Summary Notice?

If you have Medicare Part A and/or Part B, you will receive a Medicare Summary Notice in the mail every three months. The notice is a brief summary of all covered services that you can use to help you stay on top of your claims. It shows:

• All the services and/or supplies that insurance providers and suppliers billed to Medicare on your behalf during the 3-month period
• The total amount paid by Medicare
• The total maximum amount you may owe the provider
  • Note that this notice is not a bill; if you owe money to your provider, you will receive a separate bill from that provider. 

If you do not receive any covered services, treatments or supplies in a 3-month period, you will not receive a Medicare Summary Notice. If you prefer to receive this notice electronically, sign up for the eMSN service by logging into your myMedicare account here: https://account.mymedicare.gov. 

Once you are logged in, click “Get your Medicare Summary Notices (MSNs) electronically” under the “My messages” section on the account homepage.  Then, on the “My Communication Preferences” page, navigate to “Change eMSN preference,” and click “Yes” to confirm the change.

How to Appeal a Denial of Your Medicare Claim

In some cases, Medicare may deny your claim for coverage for a particular treatment or service, whether you or your provider filed the initial claim. If your claim is denied, you can file an appeal and ask Medicare to reconsider your request. 

The appeal process differs slightly based on the type of Medicare plan under which you filed your initial claim. Continue reading the sections below to learn how to file Medicare appeals for the following Medicare plans:

• Medicare Parts A and B
• Medicare Part C
• Medicare Part D
• Special Needs Program
• Program of All-Inclusive Care for the Elderly (PACE)

File an Appeal With Medicare Parts A or B

If you disagree with a coverage or payment decision made by your plan, you must file an appeal within 120 days of receiving your Medicare Summary Notice. The first step is to submit a Medicare Redetermination Request Form, found here: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/CMS20027.pdf.

Print, complete and mail the form to the address listed on the Medicare Summary Notice you receive. 

Alternatively, you can send a written request for redetermination to the same address listed on the Medicare Summary Notice you receive. The information you may need to provide on the written request is: 

• Your name, address and Medicare number
• The items and services for which you are requesting a redetermination
• An explanation of why you think the items should be covered
• The name of your representative, if applicable
• Any other pertinent information

You will receive a decision within 60 days of Medicare receiving your Redetermination Request. If your appeal is approved and Medicare reverses its decision, the changes will be reflected in your next Medicare Summary Notice. Learn more about filing an appeal for Medicare Parts A and B on the Medicare website here: https://www.medicare.gov/claims-appeals/how-do-i-file-an-appeal 

File an Appeal With Medicare Part C

If you disagree with a decision made by your Medicare Part C plan insurance provider, you can file an appeal within 60 days of receiving an initial denial notice from your provider. If you miss the provider’s appeal deadline, you must provide an explanation for doing so. Each plan has its own general guidelines for appealing a decision, which the provider will include in the initial denial notice. 

Your written appeal should include the following information:

• Your name, address and Medicare number
• The items and services for which you are requesting a redetermination
• An explanation of why you think the items should be covered
• The name of your representative, if applicable
• Any other pertinent information

In most cases, you will receive a decision from your provider within 14 days. However, if you believe your health would be harmed by the delay, you can ask for an expedited decision within 72 hours. Visit the Medicare website here (https://www.medicare.gov/claims-appeals/how-do-i-file-an-appeal) for more information.

File an Appeal With Medicare Part D 

You can file an appeal with your Medicare Part D plan if you:

• Wish to get reimbursed for prescription drugs you already paid for; OR
• Wish to get covered for a prescription that you are not currently covered for; OR
• Have not yet received a prescription but want to ask for an expedited request.

You must file the appeal directly with your Medicare Part D plan provider. The requirements vary depending on the reason for appealing. 

Appeal for Reimbursement

If you wish to be reimbursed for prescription drugs you have already purchased, you have two options to initiate the appeal:

1. Download and complete the “Model Coverage Determination Request” form found on the Centers for Medicare & Medicaid Services (CMS) webpage: https://www.cms.gov/Medicare/Appeals-and-Grievances/MedPrescriptDrugApplGriev/CoverageDeterminations-.
   • Scroll to the bottom of the page.
   • Under “Downloads,” click the “Model Coverage Determination Request Form and Instructions (ZIP)”. It will download the file to your computer.
   • When complete, mail or fax the form to your Medicare Part D plan provider. 
2. Send a written request for reimbursement to your Medicare Part D plan provider.
   • The letter should include most of the same information required in the Model Coverage Determination Request form:
     • Prescriber’s (i.e. your doctor’s) name, address and phone number
     • Information about your medical condition, diagnosis and drugs you currently take
     • Reason for your request

Requesting a Specific Prescription Benefit

If you need a certain prescription drug to treat your medical condition that you have not yet received but your Medicare Part D plan does not cover it, you can do one of the following:

1. Download and complete the “Model Coverage Determination Request” form found on the Centers for Medicare & Medicaid Services (CMS) webpage: https://www.cms.gov/Medicare/Appeals-and-Grievances/MedPrescriptDrugApplGriev/CoverageDeterminations-.
   • Scroll to the bottom of the page.
   • Under “Downloads,” click the “Model Coverage Determination Request Form and Instructions (ZIP)”. It will download the file to your computer.
   • When complete, mail or fax the form to your Medicare Part D plan provider. 
2. Send a written request for reimbursement to your plan provider
   • The letter should include most of the same information required in the Model Coverage Determination Request form:
     • Prescriber’s (i.e. your doctor’s) name, address and phone number
     • Information about your medical condition, diagnosis and drugs you currently take
     • Reason for your request
3. Request an exception from your Part D plan provider.
   • If the drug is not included in the plan’s formulary, the provider may grant you an exception based on your medical condition and whether similar prescriptions are unavailable. Learn more about the formulary in the “Medicare Part D” section of this guide.
   • Include a statement from your doctor or medical provider explaining why your request should be approved. 
4. Call your plan provider.

Regardless of the option you utilize, you will receive a decision from your plan within 72 hours  of your plan provider receiving your request. If your medical provider believes that waiting the 72-hour period would jeopardize your life or health, you can receive an expedited request, which results in a decision within 24 hours. 

To receive an expedited request, check the box next to “Check this box if you believe you need a decision within 24 hours” on the Model Coverage Determination Request form. Include a statement from your prescriber and attach it to the form. If you do not include a prescriber statement, your Part D plan may still grant you an expedited request if, after reviewing your information, it believes waiting 72 hours would pose a risk to your life or health. 

These options only apply if you have not yet received the drug. If you have received the drug and paid for it out of pocket, follow the instructions in the “Appeal for Reimbursement” section. 

File an Appeal Through a Special Needs Plan (SNP) or the Program of All-Inclusive Care for the Elderly (PACE)

Both the Program for All-Inclusive Care for the Elderly (PACE) and Special Needs Plans (SNPs) are administered by private health insurance companies. If you disagree with a decision made by your PACE or  SNP provider, you can file an appeal directly with the provider.

Coverage Through Other Health Insurance Plans

What happens if I already have Marketplace coverage?

The Health Insurance Marketplace is an online “shopping service” operated by the federal government in each state. Through the Marketplace, you can browse available public health insurance plans in your state and compare plans to determine which is best for you. 

If you already have a health insurance plan purchased through the Marketplace and become eligible for Medicare Part A, you should cancel your Marketplace coverage. The only exception is if you must buy into Medicare Part A and pay a premium, or if you were not automatically enrolled into Medicare and have chosen not to enroll. If that is the case, you can elect to obtain or keep Marketplace coverage instead of Medicare. 

You have the option to keep your existing Marketplace coverage when you become eligible for Medicare. However, you will lose any premium tax credits and other savings you were eligible for, which means your Marketplace plan could become significantly more expensive. 

What happens with my Health Savings Account?

Once you enroll in Medicare, you can no longer contribute to your Health Savings Account (HSA). However, you can continue to draw funds out of the HSA to pay for medical bills until the HSA is exhausted. 

Losing Medicare Coverage

There are only a few situations in which an individual might lose Medicare coverage after receiving it. Those who lose Medicare coverage can enroll in an alternative health insurance plan to continue receiving health care coverage. 

How can I lose Medicare coverage?

There are several things that can cause a Medicare beneficiary to lose health care coverage. Individuals will lose coverage if they:

• Do not pay their premiums for Medicare Parts A (if required) and B.
• Have a delinquent premium payment for more than 90 days.
  • A payment becomes delinquent when a beneficiary receives two previous unpaid bills.
• Have Medicare based on a disability and they return to work.
  • Medicare benefits for working disabled individuals will continue for 8.5 years as long as the individual’s condition still qualifies as a disability. After 8.5 years, Medicare coverage will stop.
• Have Medicare Part C, Part D or Medigap and do not pay required premiums, copayments or coinsurance. 

Can I regain Medicare coverage after losing it?

Yes. You can regain Medicare coverage after losing it due to missing payments, but you must wait until the General Enrollment Period. Re-enrolling in Medicare may result in late payment penalty fees for the remainder of your time on Medicare.

If you had Medicare based on a disability and lost coverage 8.5 years after returning to work, you can resume benefits if you qualify for disability benefits again or upon reaching 65 years of age. 

Medicare Coverage Limits

Most Medicare coverage is not limited, which means beneficiaries can utilize their benefits as many times as necessary. For example, a beneficiary may visit a doctor’s office as many times as he or she needs to treat a medical condition, alleviate symptoms or receive consultations. There are, however, certain benefits that have limits. 

Coverage That Is Limited

The following types of Medicare coverage are limited:

• Inpatient hospital care
• Skilled nursing facility (SNF) care 

Inpatient hospital care limits are:

• 90 days of inpatient care per benefit period, which is a period that begins on the first day of a hospital admission and ends after 60 days of no admissions
  • There are no limits to benefit periods
• 60 days of additional care beyond the 90-day benefit period limit, known as lifetime reserve days 

Skilled nursing facility (SNF) limits are:

• 100 days of care per benefit period
  • There are no lifetime reserve days associated with SNF care

What happens when you meet a Medicare limit?

Beneficiaries who are admitted into a hospital for more than 90 days in a benefit period and have already used their 60 lifetime reserve days will need to pay the full cost of the admission for the additional days until they are discharged. 

Options When You Meet Your Medicare Limit

Those who meet their Medicare coverage limits can get help paying their required costs by purchasing a Medigap policy. These plans provide up to 365 additional days of inpatient coverage that can be used after running out of lifetime reserve days. Learn more about Medigap policies, requirements and availability in the “Medigap Policies” section of this guide.